Ebook Manual of practical medicine (4/E): Part 2

(BQ) Part 2 book Manual of practical medicine has contents: Nervous system, endocrine and metabolic disorders, connective tissue disorders, oncology, geriatric medicine, substance abuse, imaging modalities in internal medicine, procedures.

Chapter Nervous System 428 Manual of Practical Medicine Abnormal flexor response (decorticate posture) Extensor response (decerebrate posture) No response Higher Functions Definitions Consciousness It is defined as the state of awareness of self and the environment Confusion It is lack of clarity and coherence of thought, perception, understanding or action It is often the first feature of cognitive impairment GCS is useful in assessing level of consciousness in a patient with head injury Best total score is 15 Mild injury 13 to 15 Moderate injury to 12 Severe injury This gives an indication of the patient’s state of consciousness and is not a substitute for neurological examination Coma It is a state of unconsciousness in which the patient does not respond to any type of external stimuli or inner need Abbreviated Coma Scale (AVPU) Stupor (or) Semiconsciousness A V P U It is a state of disturbed consciousness from which only vigorous external stimuli can produce arousal Coma Vigil (Vegetative State) Glasgow Coma Scale (GCS) Eye Opening Spontaneous To speech To pain No response Best Verbal Response Fully oriented Mild confusion Moderate confusion (inappropriate) Severe confusion (incomprehensible) No response Best Motor Response Obeys commands Localises pain Withdrawal to pain alert responds to vocal stimuli responds to pain unresponsive Patient is comatose, but the eyelids are open giving the appearance of being awake Patient may perform random limb and head movements, but there is complete inability to respond to command or to communicate Akinetic Mutism This refers to a partial or fully awake patient who is immobile and silent This state may be seen in hydrocephalus, mass in the region of third ventricle or large bilateral hemispherical lesions Abulia This is a mild form of akinetic mutism, in which patient is hypokinetic, but is able to communicate This is seen in lesions in the periaqueductal region or lower diencephalon Unresponsive States in Neurology Disorder Awareness Sleep cycle Motor function Experiences suffering Respiratory function EEG Persistent vegetative state Absent Intact No purposeful movement No Normal Polymorphic delta and theta Brain death Absent Absent None or only reflex spinal movements No Absent Silent Locked-insyndrome Present Intact Quadriplegia Preserved vertical eye movements Yes Normal Normal Akinetic mutism Present Intact Paucity of movements Yes Normal Non-specific slowing Nervous System Locked-in Syndrome (Pseudo Coma) Patients are awake, alert and selectively de-efferented They are non communicable with intact lid movements, eye movements in the vertical plane and quadriplegia with involvement of lower cranial nerves The site of lesion is either ventral pons or bilateral medulla with intact tegmentum (which contains fibres of Reticular Activating System) Infarction of ventral pons transects all descending corticospinal and corticobulbar tracts, but spares ARAS, which maintains arousal Causes Demyelination (central pontine myelinolysis) Ventral pontine infarction (basilar artery occlusion) Bilateral infarction of lateral 2/3 of cerebral peduncle Peripheral disorders associated with locked in syndrome a Severe polyneuropathy b Myasthenia gravis c Neuromuscular blocking agents Catatonia Patient appears awake and blink spontaneously There is a waxy flexibility (limbs maintain the posture implemented by the examiner) This is seen in schizophrenia Delirium This is synonymous with acute confusional state characterised by periods of agitation, heightened mental activity, increased wakefulness, hallucinations, motor hyperactivity and autonomic stimulation There is an associated impairment of attention Causes of Delirium Head injury CVA Cerebral infections Epilepsy Hypoglycaemia, DKA Hypoxia Renal or hepatic failure Electrolyte or acid-base imbalance Wernicke’s encephalopathy Septicaemia, malaria, SBE, pneumonia Heat stroke, hypothermia Toxins Alcoholic intoxication *Alcohol and drug (Barbiturates and narcotics) withdrawal 429 Psychiatric disorders Acute mania Extreme anxiety Schizophrenia (auditory hallucinations) Hysteria Note: *Alcohol withdrawal causes delirium tremens which is characterised by delirium, tremors and visual hallucinations Dementia It is a syndrome of acquired global or multifocal impairment of cognitive function involving decline in intellect, memory or personality in the presence of normal consciousness Causes of Dementia Primary dementias a Alzheimer’s disease (diffuse cortical atrophy) b Pick’s disease (circumscribed cortical atrophy, early frontal and temporal) c Frontal lobe degeneration Secondary dementias a Degenerative disorders Parkinson’s disease Hereditary ataxias Progressive supranuclear palsy (SteeleRichardson syndrome) Motor neuron disease Huntington’s chorea Multiple sclerosis b Conditions with raised intracranial tension • Primary and secondary tumours • Hydrocephalus • Chronic subdural hematoma • Carcinomatous meningitis c Vascular dementia • Multiinfarct dementia — Lacunar infarct — Thalamic infarct — Diffuse atherosclerosis • Vasculitis: SLE, polyarteritis nodosa, Behcet’s disease d Chronic infections • Syphilis, GPI • Tuberculosis • Fungal, protozoal infections Slow viral diseases: * Subacute sclerosing panencephalitis * Creutzfeldt-Jacob disease * Papova virus * HIV 430 Manual of Practical Medicine Dementia due to diffuse brain damage Anoxia Encephalitis Acute head injury Pugilistic dementia (boxers) Endocrine disorders • Chronic hypoglycaemia • Hypothyroidism • Hypo and hyperparathyroidism • Adrenal insufficiency • Cushing’s syndrome Vitamin deficiencies • Vitamin B12 deficiency • Thiamine deficiency • Niacin deficiency Toxins • Alcohol • Drug and narcotic poisoning • Heavy metal intoxication • Dialysis dementia Dementia in adolescents and young adults • Wilson’s disease Progressive myoclonic epilepsy Tuberous sclerosis Leukodystrophies Storage diseases Note: • Treatable causes Presenile Dementia It occurs before 65 years of age (Pick’s disease, Alzheimer’s disease) Senile Dementia It occurs after 65 years of age Cortical Dementia It occurs in Pick’s disease and Alzheimer’s disease Subcortical Dementia It occurs in Huntington’s disease, multiple sclerosis and HIV Differences between Alzheimer’s Disease and Pick’s Disease Features Alzheimer’s disease Pick’s disease Portion of brain affected Pathology Age of onset Clinical features Diffuse cortical involve- Confined to ment (esp hippocampus frontal and and temporal lobes) temporal lobes (lobar sclerosis) Neurofibrillary tangles, Pick’s bodies senile plaques seen seen Presenile or senile Presenile Features of diffuse Prominent cortical involvement frontoseen: Frontotemporal temporal features less prominent features seen Amnesia It is a disorder of memory characterised by inability to remember past events and to learn new information despite normal consciousness and attention As a result of head injury, memory disturbance occurs for events before (retrograde amnesia) and after the time of injury (post-traumatic amnesia) Anterograde Amnesia Impairment in learning new material which accompanies post-traumatic amnesia Duration of post-traumatic amnesia indicates the severity of head injury; the ability to learn new material often being the last cognitive deficit to recover Transient Global Amnesia It is a syndrome in which a previously normal person suddenly becomes confused and amnesic It is usually of spontaneous origin but also may be due to immersion in cold or hot water, emotional stimuli, exertion, intercourse or travel in motor vehicles There is severe impairment of recall of recent and sometimes most distant events Immediate memory is intact There is no other neurological sign It is usually benign Rarely it may be due to temporal lobe tumour, migraine or temporal lobe epilepsy Examination of Higher Mental Functions Consciousness Find out the level of consciousness of the patient (whether the patient is comatose, stuporose or delirious) Causes of Coma Trauma Cerebral contusion, concussion and laceration Subdural haematoma Extradural haematoma Cerebrovascular Disease Subarachnoid haemorrhage lntracerebral haemorrhage Massive cerebral infarction Brainstem infarction or haemorrhage Cerebellar infarction or haemorrhage Cerebral venous sinus thrombosis Nervous System Infections Meningitis Encephalitis Cerebral abscess Cerebral malaria Seizure Disorders and Raised ICT Epilepsy Space occupying lesions Endocrine and Metabolic Disturbances a Diabetes mellitus: Hypoglycaemia, ketoacidosis, hyperosmolar coma b Myxoedema c Hypocalcaemia d Hypercalcaemia e Hypoadrenalism f Hypopituitarism g Hepatic failure h Respiratory failure i Cardiac failure j Uraemia k Metabolic acidosis Metabolic alkalosis m Electrolyte disturbances (hypo and hypernatraemia) Cardiovascular Disorders Congestive cardiac failure Hypertensive encephalopathy Shock Arrhythmias Physical Agents Hyperpyrexia Hypothermia Electric shock Lightning Toxins and Others Acute poisoning Alcohol Thiamine deficiency Tropical Coma Cerebral malaria Typhoid fever Trypanosomiasis Rabies 431 Metabolic Coma Aaetiology Neurologic signs Diagnostic workup Hypoxia Myoclonus, flaccid muscle tone Cardiorespiratory disorder, polytrauma, Diabetic ketoacidosis Clouding of conciousness/coma Blood sugar > 400 mg with ketonuria Hyperosmolar coma Coma, seizure, focal signs Blood sugar > 800 mg High serum osmolarity Hypoglycaemic coma Coma, seizure, focal signs Blood sugar < 50 mg% Hepatic coma Asterixis, jaundice Elevated ammonia level Uraemia Myoclonus, asterixis, oliguria Raised renal parameters Disequilibrium syndrome Muscle cramps, seizure Postdialysis syndrome Hyponatraemia Coma and seizure Serum sodium < 126 mmol Hypernatraemia Muscle weakness, coma Serum sodium > 156 mmol Hypercalcaemia Muscle weakness, headache Calcium, phosphate, and parathormone Hypocalcaemia Tetany, seizure, coma Calcium, phosphate and parathormone Approach to Coma A comatose patient has to be approached systematically to derive maximum information The aim of physical examination is to arrive at following conclusions Localisation of coma Aetiology of coma (structural vs metabolic) Approach to the Patient I History and general examination A meticulous history and detailed general examination will give clue regarding the aetiology of coma II Neurological examination The neurological examination of a comatose patient serves purposes a To aid in determining the cause of coma b To help determine the prognosis of coma c To provide a base line For localisation of structural lesion and to assess the prognosis, the following examinations are the most helpful State of consciousness Respiratory pattern Pupillary size and reactivity 432 Manual of Practical Medicine Ocular motility Skeletal muscle motor response State of Consciousness Auditory, visual and noxious stimuli of progressively increasing intensity should be applied to the patient The maximal state of arousal, intensity of stimuli required for that and the response of the patient has to be noted Any asymmetry in the response to stimuli points towards structural lesion All patients in coma should be asked to open their eyes and look up and down Because in locked in syndrome only these voluntary movements are spared Patient will be alert and aware, but quadriplegic with lower cranial nerve paralysis, thus mimicking coma Respiration Respiratory patterns that are helpful in localising level of involvement are the following (Fig 8.1): A Cheyne-Stokes breathing i Rate of respiration will be around 30 per minute ii There is waxing and waning of respiration iii Waning of respiration is followed by apnoea for about 15 seconds Causes i Bilateral hemispheric damage ii Diencephalic insults iii Bilateral damage anywhere between forebrain and upper pons iv Prolonged circulation time as in cardiac failure ii Emergence of Cheyne-Stokes breathing in a patient with unilateral mass lesion may be a sign of herniation iii Change in pattern from Cheyne-Stokes to other patterns described is ominous B Central neurogenic hyperventilation i Refers to rapid breathing (40-70 per minute) ii Lesions of low midbrain ventral to aqueduct of Sylvius and of upper pons ventral to fourth ventricle iii Hyperpnoea cannot be ascribed to CNS lesion if PaO2 is < 70-80 mm Hg and PCO2 is greater than 40 mmHg C Apneustic breathing Apneustic breathing is a prolonged inspiratory gasp with a pause at full inspiration It is caused by lesions of the dorsolateral lower half of pons D Cluster breathing Cluster breathing results from high medullary damage, involves periodic respirations that are irregular in frequency and amplitude, with variable pauses between clusters of breaths E Ataxic breathing This is irregular in rate and rhythm and is usually due to medullary lesions Ataxic breathing and bilateral VI nerve lesion may be a warning sign of brainstem compression from an expanding lesion in posterior fossa Pupil Size and Reactivity (Fig 8.2) a Thalamic lesions cause small, reactive pupils, which are often referred to as diencephalic pupils Similar Prognosis i Stable pattern of Cheyne-Stokes respiration is a good prognostic sign Fig 8.1: Respiratory patterns in coma Fig 8.2: Pupillary defects in coma Nervous System b c d e pupillary findings are noted in many toxic-metabolic conditions resulting in coma Hypothalamic lesions or lesions elsewhere along the sympathetic pathway result in Horner’s syndrome Midbrain lesions produce three types of pupillary abnormality, depending on where the lesion occurs i Dorsal tectal lesions interrupt the pupillary light reflex, resulting in midposition eyes, which are fixed to light but react to near, although the reaction is impossible to test in the comatose patient Spontaneous fluctuations in size occur, and the ciliospinal reflex is preserved ii Nuclear midbrain lesions usually affect both sympathetic and parasympathetic pathways, resulting in fixed, irregular midposition pupils, which may be unequal iii Lesions of the third nerve in the brainstem, or after the nerve exits the brainstem parenchyma, cause wide pupillary dilation unresponsive to light Pontine lesions interrupt sympathetic pathways to cause small pupils (pinpoint pupils), which remain reactive, although magnification may be needed to observe this Lesions above the thalamus and below the pons should leave pupillary function intact, except for Horner’s syndrome in medullary or cervical spinal cord lesions Ocular Motility Preservation of normal ocular motility implies that a large portion of brainstem is intact, from the oculomotor nucleus in the midbrain to the vestibular nuclei at the pontomedullary junction Evaluation of ocular movement consists of three main elements i Abnormalities of resting position including eye deviation ii Spontaneous eye movements a Purposeful appearing eye movements occur in locked in syndrome, catatonia, pseudocoma, and persistent vegetative state b Rowing eye movements indicates brainstem is relatively intact and coma is due to metabolic or toxic cause or bilateral lesions above the brainstem c Nystagmus occurring in comatose patients suggests an irritative or epileptogenic supratentorial focus d Spontaneous conjugate vertical eye movements like ocular bobbing which is characterised by rapid downward jerk of both eyes followed by a slow return to the midposition The centre of lesion is at Pons 433 e Oculopalatal nystagmus occurs due to damage to the lower brainstem involving the GuillainMollaret triangle, which extends between the cerebellar dentate nucleus, red nucleus and inferior olive iii Reflex ocular movements This constitutes: a Oculocephalic reflex (Dolls eye movement) b Vestibulo-oculogyric reflex (Cold caloric testing) a Dolls eye phenomenon This is tested by sudden passive rotation of head in both directions laterally and flexion and extension of the neck while observing the motion of the eyes b Cold caloric testing Clinical caloric testing is commonly done by applying cold water to the tympanic membrane with the head tilted back 60 degrees from the horizontal The head tilt allows maximal stimulation of the lateral semicircular canal, which is most responsible for reflex lateral eye movements After checking to make certain that the ear canal is patent and the tympanic membrane is free of defect, 10 ml of ice-cold water is slowly injected into one ear canal Cold water applied to the tympanic membrane causes currents to be set up in the endolymph of the semicircular canal This results in a change in the baseline firing of the vestibular nerve and slow (tonic) conjugate deviation of the eyes toward the stimulated ear In an awake person, the eye deviation is minimal and is corrected with a nystagmus fast phase towards the opposite side Warm water irrigation produces reversal of flow of the endolymph, which causes a slow phase away from the stimulated ear and a normal corrective phase towards the ear By tradition, the nystagmus is named by the direction of the fast phase The mnemonic COWS (cold opposite, warm same) refers to the fast phases Simultaneous bilateral cold water application results in slow phase down and fast phase up, whereas the reverse occurs with bilateral warm water application Interpretation i Normal response indicate intact brainstem ii Absent response indicate brainstem involvement iii Abnormal dysconjugate responses occur with cranial nerve palsies, internuclear ophthalmoplegia, or restrictive eye disease Motor System Resting posture and adventitious movements are analysed 434 Manual of Practical Medicine Adventitious Movements i Tonic-clonic or other stereotyped movements signal seizure as the probable cause of decreased alertness ii Myoclonic jerking, nonrhythmic jerking movements in single or multiple muscle groups, is seen with anoxic encephalopathy or other metabolic comas, such as hepatic encephalopathy iii Rhythmic myoclonus, which must be differentiated from epileptic movements, is usually a sign of brainstem injury iv Tetany occurs with hypocalcaemia v Cerebellar fits, resulting from intermittent tonsillar herniation, are characterised by a deterioration of level of arousal, opisthotonos, respiratory rate slowing and irregularity, and pupillary dilation Differentiating Features between Structural and Metabolic Coma Fig 8.3: Postures Postures (Fig 8.3) i Head and eye deviation to one side and contralateral hemiparesis indicate supratentorial lesion, while ipsilateral hemiparesis indicates brainstem lesion ii Decerebrate posturing is bilateral extensor posture, with extension of the lower extremities and adduction and internal rotation of the shoulders and extension at the elbows and wrist Bilateral midbrain or pontine lesions are usually responsible for decerebrate posturing Less commonly, deep metabolic encephalopathies or bilateral supratentorial lesions involving the motor pathways may produce a similar pattern iii Decorticate posturing is bilateral flexion at the elbows and wrists, with shoulder adduction and extension of the lower extremities It is a much poorer localising posture because it may result from lesions in many locations but usually above the brainstem Decorticate posture is not as ominous a sign as decerebrate posture because the former occurs with many relatively reversible lesions iv Unilateral decerebrate or decorticate postures are generally less ominous than bilateral posturing Lesions causing unilateral posturing may be anywhere in the motor system from cortex to brainstem Unilateral extensor posturing is common immediately after an acute hemispheric event, followed in time by a flexor response State of consciousness: Patients with metabolic problems often have mild alterations in arousal and tend to have waxing and waning of the behavioural state Patients with acute structural lesions tend to stay at the same level of arousal or progressively deteriorate Toxins may also cause progressive decline in level of arousal Respiration: Deep, frequent respiration is most commonly due to metabolic abnormalities, but rarely it is caused by pontine lesions or by neurogenic pulmonary oedema secondary to acute structural lesions Funduscopic examination: Subhyaloid haemorrhage or papilloedema is almost pathognomonic of structural lesions Papilloedema due to increased ICP may indicate an intracranial mass lesion or hypertensive encephalopathy Papilloedema does not occur in metabolic diseases, except hypoparathyroidism, lead intoxication, and malignant hypertension Pupil size: The pupils are usually symmetrical in coma from toxic-metabolic causes Patients with metabolic or toxic encephalopathies often have small pupils with preserved reactivity Exceptions occur with methyl alcohol poisoning, which may produce dilated and unreactive pupils, or late in the course of toxic or metabolic coma if hypoxia or other permanent brain damage has occurred In terminal asphyxia, the pupils dilate initially and then become fixed at midposition within 30 minutes The initial dilation is attributed to massive sympathetic discharge Pupil reactivity: Assessment of the pupillary reflex is one of the most useful means of differentiating Nervous System 10 metabolic from structural causes of coma Pupillary reactivity is relatively resistant to metabolic insult and is usually spared in coma from drug intoxication or metabolic causes, even when other brainstem reflexes are absent Hypothermia may fix pupils, as does severe barbiturate intoxication; neuromuscular blocking agents produce midposition or small pupils, and glutethimide and atropine dilate them Ocular motility: Dysconjugate eye movements are typically a feature of structural lesions Spontaneous eye movements: Roving eye movements with full excursion most often suggest metabolic or toxic abnormalities Reflex eye movements: Reflex eye movements are normally intact in toxic-metabolic coma, except rarely in phenobarbital or phenytoin intoxication or deep metabolic coma from other causes Adventitious movement: Coma punctuated by periods of motor restlessness, tremors, or spasm is often due to toxins or drugs, such as chlorpromazine or lithium Brainstem herniation or intermittent CNS ischaemia may also produce unusual posturing movements Myoclonic jerking is generally metabolic and often anoxic in origin Muscle tone: Muscle tone is usually symmetrical and normal or decreased in metabolic coma Structural lesions cause asymmetrical muscle tone Tone may be increased, normal, or decreased by structural lesions Appearance and Behaviour This can be assessed as the patient walks into the consulting room A note is made of the way the patient carries himself including the way he has attired himself and his personal hygiene Note also from his behaviour whether he is disturbed, apathetic, agitated or confused Emotional State Assess whether the patient is elated, euphoric, excited or depressed Mood: It is the prevailing emotional state Affect: It is an emotional experience evoked by a particular stimulus Mood is characterised by a feeling of cheerfulness and happiness, a state of exceptional mental well-being or a feeling of depression Depression: This is a mood of dejection and gloom for no reason Depression may be of two types: 435 Major depressive disorder (single or recurrent episodes) Dysthymic disorder (chronic, less intense form of depression lasting for atleast two years) Emotional instability: Inappropriate elation and depression for no reason; It is seen in pseudobulbar palsy Mania: It is a distinct period of abnormal and persistently elevated or irritable mood Anxiety: It is an anticipatory reaction It may present with somatic symptoms related to autonomic nervous system or psychic symptoms or both Orientation Questions are put to the patient to test his orientation to time, place and person as follows: Time Ask the patient to tell the year, season, date, day and month Place Ask for the state, country, town, hospital and floor in which he is admitted Person Ask for the identity of his nearby relatives or neighbours Self Ask the patient’s name, age, address and qualifications Rule out confabulation, which is a filling in of forgotten memories by inappropriately recalled material from previous experience, e.g Korsakoff’s psychosis Handedness It is the preference to use the hand of a particular side (right or left) for complicated, fine and skillful motor acts Dominant hand is the hand used for combing the hair or buttoning the shirt or picking up a coin It can also be tested indirectly by asking the patient to kick a ball or to use his or her eye to see through a small hole The leg or the eye used preferentially, gives a clue to the side of cerebral dominance On asking the patient to fold his arms across the chest, the dominant arm is placed anteriorly Similarly, while asking the patient to stand at ease, the dominant hand comes posteriorly There is an anatomic difference between the sizes of dominant and nondominant cerebral hemispheres ‘Planum temporale’, which is adjacent to the auditory centre of Heschl’s transverse gyrus, is larger in the left hemisphere in the right handed individuals Left handedness may be hereditary or may result from disease of the left hemisphere in early life 436 Manual of Practical Medicine Left hemisphere dominance for language occurs in 95% of right handed people Even in 50% of left handed individuals, left hemisphere is dominant General Intelligence It is necessary to ascertain the patient’s general intellectual ability as evidenced by his educational standard and work records before assessing his intelligence Intelligence is assessed by testing the following: a Abstract thinking: It is tested by asking the patient to explain the meaning of a common proverb b Reasoning: This is tested by asking him to compare objects or by asking him to differentiate between a lie and a mistake Test his power to appreciate similarities and dissimilarities between two objects, animals, etc c Judgement: It is tested by asking the patient various questions, like what he would on seeing a house on fire or what he would when he finds a stamped envelope on the road d Attention: It is tested by asking the patient to sequential subtraction of from 100 down to zero and by forward and reverse digit spans e Calculation: It is tested by asking the patient to solve simple numerical problems drome Immediate memory requires sustained attention also b Recent memory: It means recall of information presented within minutes, hours and days It is tested by asking the patient to recall certain important recent events or current affairs and by asking him to remember three unrelated common objects or a simple address told to him, a few minutes ago It is impaired in dementia, acute confusional syndromes and amnesia This is tested after two minutes and five minutes depending on the degree of amnesia c Long-term or Secondary or Remote memory: It means memory for past events It can be tested by asking the dates and salient facts of some well known but distant public events or names of political figures or locations of major cities It incorporates the meaning of information rather than exact words or pictures Perceptions Delusions: These are false beliefs which continue to be held despite evidence to the contrary Hallucinations: These are false impressions referred to the organs of special senses in the absence of a stimulus, e.g., temporal lobe epilepsy, alcohol withdrawal, schizophrenia Memory Illusions: These are misinterpretations of stimuli It is the power to retain and recall past experiences Obsessions: These are recurrent and persistent thoughts, which intrudes into the patient’s mind despite best effort to get rid of them Components of Memory Reception Registration Retention Recall Types a Immediate or short-term memory: It is the memory for events of a few seconds duration This holds information close to consciousness for a few seconds only This is tested by asking the patient to reproduce a string of numerals Example: • Digit span, forwards, backwards • Spell ‘World’ backwards Immediate memory is impaired in acute confusional syndrome, Wernicke-Korsakoff syndrome and mostly retained in dementia and amnesic syn- Visuospatial Functions Ask the patient to copy a drawing of a five pointed star or three dimensional box Constructional apraxia or visuospatial agnosia results in difficulty in drawing the lines required in the correct spatial orientation or position ‘Perseveration’ or visual neglect is revealed by this test Apraxia It is a defect in the ability to carry out known acts in the absence of motor weakness, sensory loss or ataxia Consequently, the apraxic patient is unable to make use of objects, though their use can be recognised and described It results from damage to the left parietal cortex or to parietal white matter of the left or of both hemispheres, or from disease of the connections between the two hemispheres through the corpus callosum 824 Manual of Practical Medicine Prothrombin time Complete haemogram a Haematocrit Females Males b Haemoglobin Females Males c RBC count Males d e f g h Females Mean corpuscular Hb MCHC MCV RBC life span WBC count Total count Differential count i Platelet count j Life span Clot retraction time Reticulocyte count 10 ESR Males Females 11 CRP 12 Complement C3 C4 13 Immunoglobulins IgA IgM IgG IgE IgD 10 to 15 sec 35 to 40% 40 to 45% 13 to 15 gm/dl 15 to 17 gm/dl 4.5 to 5.5 millions/ cmm to 4.5 millions/cmm 25 to 35 pg/cell 30 to 35 g/dl 78 to 98 fl 120 days 4000 to 11,000 cells/ cmm P60, L35, E5 to lakhs/cmm 10 days Onset at hour and Completion at hours 0.5 to 1.5% to 20 mm/hr to 30 mm/hr < 10 mg/L 75 to 150 mg/dl 25 to 50 mg/dl 100 to 500 mg/dl 50 to 250 mg/dl 800 to 1800 mg/dl < 0.025 mg/dl to mg/dl Urine Calcium Catecholamines Copper Cortisol Creatinine Males Females HIAA Hydroxy proline Metanephrine to 250 mg/day < 500 μg/day 25 to 100 mg/day 25 to 100 mg/day to gm/day 0.5 to 1.5 gm/day < mg/day 25 to 75 mg/day < 0.9 mg/day Vanillyl mandelic acid Protein Sodium Urobilinogen to mg/day to 150 mg/day 100 to 250 mEq/day to 3.5 mg/day Stool Normal weight Fat Stercobilinogen < 200 gm/day < gm/day 40 to 280 mg/day Sweat Sodium Chloride < 60 mEq/l < 70 mEq/l Hormones Growth hormone Insulin Thyroxine (T4) Triiodothyronine (T3) TSH Parathormone Prolactin Males Females Free testosterone Males Females Progesterone Males Females Follicular phase Luteal phase 1st trimester 3rd trimester Post-menopausal LH Males Females Follicular phase Luteal phase Midcycle Post-menopausal FSH Males Females Follicular phase Luteal phase Midcycle Post-menopausal < ng/ml < 20 µU/mL to 12 μg/dl 80 to 200 ng/dl 0.4 to 6.2 μU/ml 10 to 50 pg/ml to 15 ng/ml to 25 ng/ml 50 to 250 pg/ml to pg/ml < 0.5 ng/ml 0.1 to 1.5 ng/ml 2.5 to 28 ng/ml to 47 ng/ml 55 to 255 ng/ml < 0.5 ng/ml to IU/L 1.4 to 11.5 IU/L 0.1 to 16 IU/L 20 to 75 IU/L 8.5 to 46.5 IU/L 2.5 to 20 IU/L to 20 IU/L 1.5 to 10 IU/L 10 to 23 IU/L 18 to 126 IU/L Laboratory Reference Values Cortisol (morning) Aldosterone ACTH (8 AM-supine, fasting) β-hCG Nonpregnant to 25 μg/dl 10 to 150 ng/l < 60 pg/ml mIU/ml Cerebrospinal Fluid Glucose 40 to 70 mg/dl Total protein WBC’s TC DC L M N Chloride Pressure Volume 825 20 to 50 mg/dl < 5/µL 60 to 70% 30 to 50% 0% 116 to 122 mmol/L 50 to 180 mm water 150 ml Index A Abbreviated coma scale 428 Abdomen 269 Abdominal reflexes 490 scan 792 Abetalipoproteinaemia 552 Abnormal responses 492 Abnormalities of gait 489 tendon reflexes 494 Absent breath sounds 216 Absolute reticulocyte count 345 Abulia 428 Accelerated hypertension 89 Accessory nerve 474 Achalasia cardia 286 Acid-base balance 422 Acidosis 424 Acoustic neuroma 473 Acquired causes of late onset ataxia 556 hypothyroidism 622 Actions of calcitonin 628 insulin 648 parathormone 628 Acute alcohol hepatitis 771 central cervical spinal cord injury 572 complications of diabetes 661 coronary syndromes 179 diarrhoea 293 glomerulonephritis 407 interstitial nephritis 411 intoxication 772 kidney injury 411 lymphoblastic leukaemia 375 myeloid leukaemia 369 pancreatitis 334 pericarditis 112 poststreptococcal GN 408 rejection 51 renal failure 411 respiratory distress syndrome 261 thyroiditis 625 transverse myelitis 579 Addison’s disease 637 Adipsic hypernatraemia 614 Adrenal crisis 640 glands 634 insufficiency 637, 681 Advantages of MRI 801 Aetiology of aplastic anaemia 360 cancers 726 oedema 37 Agnosia 437 Airway obstruction 742 Akinetic mutism 428 Alcohol and central nervous system 772 drug interactions 774 lymphatic system 774 malignancy 774 Alcohol dementia 772 withdrawal 775 Alcoholic cerebellar degeneration 772 cirrhosis 318 coma 772, 775 myopathy 773 Algorithm for ABG analysis 426 Alkalosis 425 Allergic angiitis 718 Allogeneic stem cell transplant 393 Alopecia 758 Ambiguous genitalia 643 Amnesia 430 Amoebic abscess 316 Amyotrophic lateral sclerosis 547 Anaemia 347 Anaemia of chronic disease 354 Anal cancer 727, 730, 731, 748 Analysis of ECG 115 Anatomical peculiarities 446, 456, 465 Ancillary diagnostic supportive tests 537 Angina pectoris 79, 80 Anginal equivalent 79 Angiography 790 Ankylosing spondylitis 705 Anomalous pulmonary venous connection 139 Anorexia 728, 756 nervosa 75 Anterior lobe 606 spinal artery syndrome 569 Anthropometric classification 14 Anticancer drugs 747 Antiemetics 756 Antigen presenting cells 46 Antihypertensive therapy 178 Aortic arch syndrome 719 regurgitation 156 root to right heart shunt 124 stenosis 154 Aorto-pulmonary level shunt 124 Aplastic anaemia 360 Apnoea-hypopnoea index 232 Approach to acid-base disorders 425 coma 431 patient 431 Apraxia 436 Arrangement of fibres 568 sensory fibres 503 Arterial blood gas analysis 225 occlusion 36 pulse 82 puncture 819 Arteriovenous malformation 536 Arthritis 696 Arthritogenic bacteria in reactive arthritis 707 Ascites 324 Ascitic fluid aspiration 809 Ascorbic acid 65 Ataxia 557 telangiectasia 518, 553 Ataxic disorders 550, 552-554 828 Manual of Practical Medicine Atlanto-axial dislocation 588 Atlanto-occipital synostosis 587 Atrial septal defect 128 Audiometric tests 470 Austin-Flint murmur 158 Autoantibodies in SLE 709 Autoimmune disease 51, 638 hepatitis 314 Autologous BMT 392 stem cell transplant 393 Automated full blood analysis 347 Automatic motor activities during sleep 440 Autonomic nervous system 565 neuropathy 565 Autosomal dominant inheritance 43 recessive inheritance 44 late onset ataxia 556 AV node 120 Axial arthritis 696 B Bacterial thyroiditis 625 Bald tongue 12 Ball’s disease 741 Barber’s chair sign 507 Barnett’s classification 584 Basal ganglia 477 Basilar invagination 587 Basophils 364 Beau’s line 25 Becker’s dystrophy 597 Bed wetting 441 Bedside cardiovascular reflex test 565 Behỗets syndrome 720 Bells palsy 468 Benign intracranial hypertension 540 positional vertigo 472 Berger’s disease 409 Beta cell tumour 681 Bi-fascicular block 110 Biliary cirrhosis 319 obstruction 743 Binocular visual loss 451 Biotin 64 Biphasic murmurs 104 Biventricular hypertrophy 108 Black nail 26 Bladder cancer 727, 731, 732, 754 innervation 583 Blood pressure 87, 88 supply of spinal cord 569 transfusion 362 Bloody tap 807 Blue nail 26 B-lymphocytes 47 Bone 699, 774 Bone and joint tuberculosis 242 Bone marrow aspiration 810 transplantation 391 Borders of lung 200 Bowel sounds 282 Brachytherapy 746 Bradyarrhythmias 122 Brain death 536 metastasis 738 Breast cancer 727, 730, 732, 748 Breath sounds 216 Broad complex tachycardia 121 Bronchial asthma 227 Bronchiectasis 236 Bronchogenic carcinoma 258 Bronchopulmonary segments 200 Bronchoscopy 226 Bruit 282 Budd-Chiari syndrome 334 Bulimia 75 C Cachexia 728, 756 Cadaver donor selection 338 Calcium 68 Caloric testing 471 Canadian Heart Association grading of angina 79 Cancer 724 anorexia 728 cervix 754 Carcinoid tumours 302 Cardiac abnormalities 127 arrest 195 causes 33 cirrhosis 321 failure 163 malposition 124 tamponade 195 transplantation 197 Cardinal rules of percussion 213 Cardiogenic pulmonary oedema 166 shock 39 Cardiopulmonary resuscitation 196 Cardiovascular infections 735 system 77, 697, 774 Cardioversion 197 Catamenial pneumothorax 256 Cataplexy 440 Catatonia 429 Cell biology of cancer 724 Central core disease 599 nervous system 699 pontine myelinosis 773 Centronuclear myopathy 599 Cerebellar lesions 501 Cerebellum 499 Cerebral diplegia 578 palsy 578 tumours 541 Cerebrospinal fluid 825 Cerebrotendinous xanthomatosis 552 Cerebrovascular disease 772 disorders 518 Cervical cancer 728 spondylosis 573 Cervicomedullary junction 580 Cervix cancer 731, 732 Cessation methods 778 process 778 Characteristics of anginal pain 79 disease in old age 762 smokers 776 Charcot-Marie tooth disease 594 Chemotherapy 746, 759 Chest deformities 208 film 782 pain 33, 204 X-ray 222 Chimerism 44 Cholestanolosis 552 Chromium 70 Chromosomal abnormalities 43 disorders 127 Chronic bronchitis 233 GN 410 hepatitis 311, 312 inflammatory demyelinating polyneuropathy 593 interstitial nephritis 411 kidney disease 414 Index 829 lymphocytic leukaemia 377 thyroiditis 626 myeloid leukaemia 373 obstructive pulmonary disease 233 pancreatitis 336 rejection 51 renal failure 414 thyroiditis 626 struma lymphomatosa 626 Churg-Strauss disease 718 Chylomicrons 684 Chylothorax 255 Chylous ascites 325 Circadian rhythm sleep disorders 441 Cirrhosis of liver 317 Cisternal puncture 808 Clinical classification of diarrhoea 293 pulmonary hypertension 264 stroke 519 Clinical consequences of infective endocarditis 161 manifestations of cerebellar dysfunction 500 Clonus 481 Closed mitral valvotomy 150 Clubbing 204 Coarctation of aorta 138 Cobalt 70 Cockayne syndrome 553 Cognitive scales 446 Collateral circulation 322 Colon cancer 748 Colorectal cancer 727, 729, 731 Colour of hair skin 24 Coma 428, 430 vigil 428 Common chromosomal disorders 45 involuntary movements 486 mediastinal masses 260 organisms 250 sites of aneurysm 535 types of lung cancer 258 Complete transposition of great vessels 142 Complications of cirrhosis 321 endoscopy 291 hypertension 179 insulin therapy 651 peptic ulcer disease 289 sternal puncture 811 therapy 756 Compressive myelopathy 579 Computed tomography 795 Congenital abnormalities of coronary arteries 145 aortic stenosis 137 ataxias 551 complete heart block 144 heart diseases 123 Horner’s 566 jaundice 307 muscular dystrophy 598 myopathies 599 TB 247 Congenitally corrected transposition of great vessels 142 Congestive heart failure 682 states 284 Connective tissue disorders 695 Consciousness 428, 430 Constipation 756 Contents of cigarette smoke 776 Continuous ambulatory peritoneal dialysis 418 murmurs 103 Contraindications cardioversion 197 cytotoxic therapy 814 Contrast MRI 190 Control of arterial blood pressure 39 Copper 70 Coronary arteriovenous fistula 145 artery 146 Cortical sensations 507 venous thrombosis 531 Cough 201 Crack pot resonance 214 Cranial arteritis 719 nerves 548 Craniopharyngioma 612 Craniovertebral junction anomalies 586 Creatinine clearance 401 Crest syndrome 715 Creutzfeldt-Jakob disease 563 Crigler-Najjar syndrome 307 Crohn’s disease 298 Cryptic miliary tuberculosis 241 Cryptogenic cirrhosis 319 CT abdomen 800 angiography 795 brain 795 chest 795 coronary angiography 799 scan 225, 795 Curative radiation therapy 746 Cushing’s syndrome 635, 737 Cutaneous afferent innervation 502 Cyanosis 81 Cytokine antagonist 704 D De Quervain’s thyroiditis 625 Deafness 472 Decreased body hair distribution Deep tendon reflexes 493 Dejerine-Sottas disease 595 Delirium 429 Dementia 429 Development of infective endocarditis 161 Devic’s disease 579 Dextrocardia 127 Diabetes insipidus 613 mellitus 645 Diabetic foot 674 hand syndrome 669 nephropathy 669, 675 neuropathy 671 retinopathy 667 Diagnosis of gestational DM 676 rheumatic fever 146 Diagnostic approach to dysphagia 285 criteria for CIDP 594 Dialysis 417 Diarrhoea 292 Diastolic murmurs 103 Dipsogenic DI 614 Dipstick testing 396 Disadvantages of MRI 803 Disorders of immunoglobulins 49 neurohypophysis 613 parathyroid gland 628, 632 white cells 363 Dispersed immune cells 46 Distributive shock 39 Disturbances of hydrogen ion homeostasis 424 Drug 600, 680 fever 29 induced lupus 711 Dry tap 806, 809, 811 Dubin-Johnson syndrome 308 Duchenne dystrophy 597 830 Manual of Practical Medicine Dural sinus thrombosis 531 Dysarthria 443 Dysphagia 284 Dyspnoea 78, 203 Dyssomnias 439 Dystrophia myotonica 599 E Eaton-Lambert syndrome 602 Ebstein’s anomaly 140 ECG features of COPD 115 hypothermia 115 ECG in acute pulmonary embolism 114 coronary artery disease 111 electrolyte imbalance 113 various arrhythmias 115 Echocardiography 794 Ectopic acromegaly 737 ACTH syndrome 737 Effect of alcohol on liver 770 diabetes on pregnancy 676 sleep deprivation 439 Eighth cranial nerve 469 Eisenmenger syndrome 133 Ejection clicks 100 Electrical axis 106 Electrocardiogram 106 Eleventh cranial nerve 474 Embryology 133 Emphysema 233 Empty sella syndrome 612 Empyema thoracis 254 Encephalitis 562 Endobronchial and laryngeal tuberculosis 242 Endocrine causes of hyperparathyroidism 632 infections 735 metabolic disorders 605 syndromes 735 Endometrial cancer 754 Endoscopy 290 Endotracheal intubation 820 End-stage renal disease 417 Energy yielding macronutrients 54 Eosinophils 47, 363 Epidural abscess 572 haemorrhage and haematomyelia 573 Epilepsy 511 in pregnant women 516 Epileptic seizures 511 Essential neurological signs 537 thrombocythaemia 366 Ethanol 681 Evaluation of nephrotic syndrome 407 Examination of auditory function 469 cranial nerves 446 higher mental functions 430 III, IV and VI cranial nerves 456 motor function 466 neck 206 veins 90 reflexes 467 respiratory system 207 secretory functions 467 sensory functions 466 skin speech and language 444 Examples of monoclonal gammopathies 382 Excess carotenes 60 hair External features of cardiac disease 92 manifestations of respiratory diseases 207 Extra-articular features 708 Extracardiac obstructive shock 39 Extrapyramidal system 477 Extravasation 756 Extreme anaemia 729 Eye signs in parkinsonism 544 Ezetimibe 687 F Facial nerve 465 involvement in leprosy 468 Facio-scapulo-humeral dystrophy 598 Factitious hypoglycaemia 680 Factors determining rate of heat production 27 identifying high risk patients 144 increasing sickling 357 influencing insulin absorption 651 prognosis 172 precipitating asthma 228 predisposing to bleeding 322 bronchiectasis 236 Falciparum malaria 682 Familial benign hypercalcaemia 631 hypocalciuric hypercalcaemia 631 Fascicular blocks 109 Fasting hypoglycaemia 680 Fatty liver 771 Febrile convulsions 27 Fed hypoglycaemias 683 Fever 27, 729 Fever with exanthems 27 relative bradycardia 27 Fibrates 688 Fibrosis 220 Fifth cranial nerve 463 Fingers 19, 20 First cranial nerve 446 heart sound 97 Fissured tongue 11 Fluid and electrolyte imbalance 419 Fluorine 69 Foetal alcohol syndrome 773 Folic acid 65 Foramen magnum 580 Forward and backward heart failure 164 Fourth heart sound 99 Friction rub 282 Friedreich’s ataxia 553 Frontal lobe lesions 444 Fulminant hepatic failure 326 Functional murmurs 105 Functions of occipital lobe 445 parietal lobe 444 sensory cortex 507 skin 23 sleep 439 temporal lobe 445 vitamin A 59 C 65 Fundamentals in genetics 42 Fundus in cardiology 92 G Gallbladder 276 Gas diffusion capacity 225 Gastric cancer 729, 731, 748 carcinoma 726 ulcer and malignancy 304 Gastrointestinal bleeding 291 system 284, 697 tract infection 734 Index 831 Gastro-oesophageal reflux disease 287 General principles of auscultation 215 Genes 724 Genetic classification 546 disorders 127 Genitourinary system 774 tuberculosis 242 Genomic imprinting 45 Geographic tongue 11 Geriatric medicine 761 GI toxicity 757 Giant cell arteritis 719 Giants of geriatric medicine 764 Gilbert’s syndrome 308 Glasgow coma scale 428 Glomerular injury 729 Glomerulonephritis 407 Glomerulopathies 404 Glossopharyngeal nerves 473 Glucose homeostasis 679 Goals of insulin therapy 647 Goodpasture’s syndrome 408 Grading of ascites 281 dyspnoea 203 Granulomatosis 718 Granulomatous thyroiditis 625 Graphaesthesia 508 Guillain-Barré syndrome 592 Gynaecomastia 644, 737 H Haematemesis 291 Haematochezia 291 Haematologic syndromes 737 values 823 Haematological disorders 284 malignancies 368 Haematology 341, 774 Haematopoiesis 342 Haematopoietic growth factors 342 stem cell 342 differentiation 342 transplantation 393 Haemochromatosis 331 Haemodialysis 418 Haemofiltration 418 Haemolytic anaemia 355 uremic syndrome 758 Haemoptysis 202, 742 Haemorrhagic cystitis 757 Haemothorax 255 Hairy cell leukaemia 378 tongue 11 Handedness 435 Hands 19 Hashimoto’s thyroiditis 626 Head and neck cancer 727, 730, 731, 754 Headache 537, 538 Heart block 122 murmurs 101 sounds 97 Heat loss from body 27 Heel pad thickness 22 Helicobacter pylori 287 Hemiblocks 109 Henoch-Schönlein purpura 409 Hepatic cirrhosis 771 coma 327 encephalopathy 327 failure 681 segments 304 Hepatocellular carcinoma 329, 727, 730, 731 Hepatoma 329 Hepatopulmonary syndrome 329 Hepatorenal syndrome 328 Hereditary ataxia 550 sensory motor neuropathy 594 spherocytosis 356 High arched palate CSF protein 808 density lipoprotein 684 Highly toxic 703 Hirsutism 644 Histocompatibility antigens 51 HIV 247 associated nephropathy 405 Hodgkin’s disease 379 Holandric inheritance 44 Holiday heart syndrome 774 Hormonal response to hypoglycaemia 679 Hormones 824 Horner’s syndrome 566 Human antibody infusion reactions 757 insulins 648 Hydatid thrill 282 Hydrogen ion homeostasis 422 Hyperacute rejection 51 Hypercalcaemia 113, 628, 735 in malignancy 631 Hypercalcaemic crisis 631 Hyperkalaemia 67, 113, 422 Hyperlipoproteinaemias 683 Hypermagnesaemia 113 Hypernatraemia 67, 420 Hyperosmolar coma 665 Hyperpituitarism 608 Hyperprolactinaemia 610 Hyperpyrexia 30 Hypersecretory disorders of anterior pituitary 608 Hypertensive emergency 89 states 89 urgency 89 Hyperthyroidism 617 Hypertonia 480 Hypertrichosis Hypertrophic obstructive cardiomyopathy 191 osteoarthropathy 729 Hypervitaminosis C 66 D 62 Hypocalcaemia 113 Hypocalcaemic disorder 632 Hypoglossal nerve 475 Hypoglycaemia in adults 679 Hypokalaemia 67, 113, 421 Hypomagnesaemia 113 Hyponatraemia 66, 420, 736 Hypophosphataemia 68 Hypopituitarism 606 Hypothalamus and pituitary gland 606 Hypothermic coma 624 Hypothyroidism 621 Hypotonia 481 I Idiopathic dilatation of pulmonary artery 145 haemochromatosis 333 late onset ataxia 556 Imaging modalities in internal medicine 781 Immune system and basis of immunity 46 thrombocytopenic purpura 387 Immunodeficiency states 49 Immunoglobulins 49 Immunopathology 382 Immunosuppression 339 Immunosuppressive therapy in renal transplantation 419 832 Manual of Practical Medicine Impaired fertility 758 Importance of auscultation 216 Increased intracranial pressure 738 Indications for DC shock 197 permanent pacemakers 123 pleural aspiration 806 sleep study 232 therapeutic aspiration 806 urgent dialysis 414 Indications of tracheostomy 819 Infections in cancer patients 733 Infective endocarditis 161 Inflammatory bowel disease 298 muscle disease 600 Innocent murmurs 105 Inorganic nutrients 66 Insomnia 440 Inspection of eyes 456 optic nerve head and fundus 451 Inspiratory tracheal descent 211 Insulin analogues 648 autoantibodies 682 delivery systems 650 receptor autoantibodies 682 regimens 650 therapy 647 Insulinomas 681 Insulitis 647 Intermediate density lipoprotein 684 Intermittent peritoneal dialysis 418 International classification of sleep disorders 439 Internuclear lesions 460 Interstitial lung disease 257 pneumonitis 757 Intestinal obstruction 742 Intracerebral haemorrhage 532 leucocytostasis 741 Intravenous urography pyelography 790 Introduction to internal medicine Inverted reflexes 498 Involuntary movements 486 Iodine 69 Iron 68 deficiency 69, 349 anaemia 348 excess 69 metabolism 348 Ironed out tongue 12 Irritable bowel syndrome 301 Ischaemic colitis 302 Isletitis 647 Isolated systolic hypertension 88, 172 IVC obstruction 274 J Jaundice 306 Jet-Lag syndrome 441 Jones criteria 146 Jugular venous pressure 90 pulse 91 K Kawasaki disease 720 Kidney 276 biopsy 812 Klippel-Feil anomaly 587 Koilonychia 24 Korotkoff sounds 87 L Labile hypertension 89 Laboratory reference values 823 Laceration 572 Lactic acidosis 666 Lacunar infarction 530 syndromes 530 Large veins and arteries 795 Late effects of cancer therapy 758 Leflunomide 703 Left atrial enlargement 107 bundle branch block 109 sided effusions 255 ventricular hypertrophy 107 Lesions of occipital lobe 445 temporal lobe 445 Vth cranial nerve 465 Leukaemias 369 Levine and Freeman’s grading of murmurs 101 Lhermitte’s sign 507 Limb girdle muscular dystrophy 597 Limited joint mobility 669 Lindsay nail 25 Linear scleroderma 715 Lipoproteins 684 Liver 275 abscess 315 biopsy 811 needles 811 function tests 304 transplantation 337 Lobar functions 444 Localisation of cerebellar lesions 501 spinal cord lesions 580 Locked-in syndrome 429 Long-term complications of diabetes 667 Loss of secondary sexual character Low density lipoprotein 684 set ears Lower motor neurons 477 retrosternal pain 204 Lumbar canal stenosis 574 disc prolapse 576 puncture 807 needle 807 Luminal phase 295 Lung abscess 249 cancer 727, 730, 732, 754 function tests 221 transplantation 268 Lymph nodes 697 Lymphocytes 363 Lymphocytic thyroiditis 626 Lymphoid malignancies 368 Lymphoma 379, 381 M Macrocytosis 351 Macrophages 47 Madras motor neuron disease 548 Magnesium 69, 633 deficiency 633 Magnetic resonance imaging 800 Maintenance of central venous cannulation 817 Major sites of collaterals 322 Malabsorption 295 Male osteoporosis 692 Malignant ascites 742 effusions 254, 741 hypertension 89 melanoma 755 pericardial effusion 741 pleural effusion 742 tumours of thyroid 628 ulcer 289 Management of acute severe asthma 232 ARF 414 Index 833 asthma 231 bronchial asthma 229 chronic hepatitis B 312 C 313 diabetic neuropathies 673 DVT 268 hypertensive crisis 179 nocturnal asthma 232 pyogenic abscess 316 tuberculosis 243 UTI 403 Management protocol 745 Manganese 70 Manipulation of blood products 362 Marchiafava-Bignami syndrome 772 Marfan’s syndrome 15 Marrow aspiration and infusion 392 Mast cell series 47 Maximum normal oral temperature 27 Measurement of chest expansion 211 Mechanism of closure of defect 130 degeneration 573 diarrhoea 293 pleural fluid formation 251 blood vessel damage 716 production of headache 538 Mediastinal mass 260 Medullary carcinoma 628 Megaloblastic anaemia 351 Melaena 291 Meniere’s disease 473 Meningeal carcinomatosis 738 Meningitis 560 Metabolic disorders 552 liver disease 330 syndromes 729 Metabolism of alcohol 770 bilirubin 306 Metastatic cancer 743 Methods of collection of urine specimens 396 testing coordination 484 Methotrexate 702 Microalbuminuria 400 Mid-systolic clicks 100 Migration of lymphocytes 46 Miliary tuberculosis 241 Mitochondrial disorders 45 encephalomyopathies 552 Mitral regurgitation 151 stenosis 147 valve prolapse syndrome 153 Mixed connective tissue disease 712 MND with dementia 549 parkinsonism 549 Modification of chronic therapy 678 Modified Osserman scale 601 Monoarthritis 696 Monocular visual loss 451 Monocytes 364 Monofilament test 672 Monomelic amyotrophy 548 Morphoea 715 Mosaicism 44 Most common causes of paraplegia 582 Motor dysphagia 285 neuron disease 546 unit 477 Movement disorders 543 Movement of chest 209 spine 567 MRI scan 225 Mucinous ascites 325 Mucocutaneous lymph node syndrome 720 Mucosal phase 295 Multiple level shunts 124 myeloma 382 sclerosis 557 Muscle 697 sensitivity 507 wasting in lower limbs 479 upper limbs 478 Muscular dystrophies 596 Myasthenia gravis 601 Myasthenic crisis 601 syndrome 602 Myelodysplastic syndromes 378 Myelofibrosis 367 Myelogram appearance 583 Myelophthisic anaemia 368 Myeloproliferative disorders 365 Myocardial infarction 182 injury 111 ischaemia 111 necrosis 111 Myocarditis 190 Myopathy 600 Myotonia 482 congenita 600 Myxoedema coma 624, 625 N Nails in clinical medicine 24 Narcolepsy 440 Natural killer cells 47 Nature of marrow stem cell 342 Nausea and vomiting 728, 756 Needle 808, 810 Negative phenomena 502 Nemaline myopathy 599 Neonatal Graves’ disease 621 hyperthyroidism 621 Neoplasia 283 Neoplastic disease of central nervous system 541 Nephritic syndrome 404 Nephrogenic DI 614 Nephrology 395 Nephrotic syndrome 405 Nervous system 427 Neuroanatomy of sleep 438 Neurocutaneous syndromes 517 Neurofibromatosis 517 Neurogenic claudication 36 Neurohypophysis 606 Neurologic syndromes 738 Neuromuscular system 477 Neuromyelitis optica 579 Neutrophil 363 polymorphs 47 New York Heart Association 78 Niacin 63 excess 64 Nickel 70 Nicotinamide 63 Nicotinic acid 63, 687 Ninth and tenth cranial nerves 473 Non B-cell tumour 681 Non-ACTH-dependent 635 Non-alcoholic fatty liver disease 317 Non-articular manifestations of rheumatoid arthritis 697 Non-compressive myelopathy 571 Non-energy yielding carbohydrates 54 Non-Hodgkin’s lymphoma 380 Non-infective endocarditis 163 Non-islet cell tumour hypoglycaemia 737 Non-motor 544 Non-organ specific disorders 52 Non-pharmacologic measures 166 Nonsteroidal anti-inflammatory drugs 701 Normal blood pressure 88 chromosome number and structure 42 834 Manual of Practical Medicine reference values in haematology 345 temperature regulation in body 26 Nuclei of cerebellum 499 Nucleus 463 Numerical chromosome aberrations 43 Nutrients 54 Nutrition 53, 478 Nutritional deficiency syndrome 773 disorders 55 Nystagmus 461 O O’ Sullivan-Mahan criteria 676 Obesity 18, 72 Obstructive diseases 227 sleep apnoea-hypopnoea syndrome 232 Occipitalisation of atlas 587 Ocular manifestations 668 motility 433 movements 459 Oculopharyngeal dystrophy 598 Oesophageal cancer 726, 729, 731, 748 Oesophagus 773 Olfactory nerve 446 Oligemic shock 39 Oncologic emergencies 738 Oncology 723 Onset and course of symptoms 298 Open mitral valvotomy/commissurotomy 150 Opening snap (OS) 100 Optic nerve 447, 451 Orbit and eye 794 Organ specific disorders 51 Orthopnoea 78 Orthostatic hypotension 88 Osmotic diarrhoea 293 Osteoarthritis 705 Osteomalacia 61, 689 Osteoporosis 690 Ovarian cancer 728, 731, 732, 754 P Paget’s disease 692 Pain 32, 728, 755 due to disorders of GIT 34 insensitive structures 538 sensitive structures 538 Painful hepatomegaly 283 Painless thyroiditis 626 Palliative radiation therapy 746 Palpation of gallbladder 277 kidneys 278 liver 277 spleen 277 urinary bladder 279 Pancoast syndrome 204 Pancreatic cancer 727, 730, 731 Pancytopenia 360 Paradoxical hypertension 89 Paramyotonia congenita 600 Paraneoplastic syndromes 735 Paraplegia 578 Paraplegia in extension 582 flexion 582 Parapneumonic effusion 253 Parasomnias 439, 440 Parasternal impulse 95 Parietal lobe lesions 445 Parkinson’s disease 543 Parkinsonism plus syndromes 545 Paroxysmal AV nodal tachycardia 120 hypertension 89 nocturnal dyspnoea 78 symptoms 558 Passing nasogastric tube 817 Passive smoking 777 Patent ductus arteriosus 131 Pathological causes of nutritional disorders 55 Q-wave 115 stages in development of pneumonia 247 Pathophysiologic classification of proteinuria 399 Pathophysiology of DKA 661 oedema 37 stroke 519 Patterns of fever 27 Pavor nocturnus 440 Pellagra 64 Peptic ulcer 287, 288 disease 287 Percussion of cyst 282 lung fields 213 Percussion on left side 215 right side 214 Percutaneous balloon valvuloplasty 150 central venous cannulation 815 Performance status 733 Pericardial knock 100 rub 100 Pericardiocentesis 808 Pericarditis 194 Perilymphatic leaks 472 Periodic Cushing’s syndrome 635 Peripheral blood stem cell transplantation 394 film morphology 346 labyrinthine disorders 472 neuropathy 557, 589, 773 vascular pain 36 Persistent flaccid paraplegia in UMN lesions 582 Phaeochromocytoma 640 Pharmacologic therapy 167 Pharmacology of cigarette smoke 776 Phosphorus 68 Photodynamic therapy 746 Physiological variation of temperature 27 Pituitary hyperplasia 612 tumours 611 Plain abdominal film 782 Plain X-ray skull 786 Plantar reflex 492 Plasma cell dyscrasias 381 Platybasia 587 Platypnoea 79 Pleural aspiration and biopsy 806 percutaneous pleural biopsy 226 Pleural aspiration needle 806 biopsy 806 border 200 effusion 251 fluid analysis 252 pain 204 Plummer nail 25 Pneumonia 247 Pneumothorax 255 Polyarteritis nodosa 716 Polyarthritis 696 Polycystic kidney disease 411 liver disease 315 Polycythaemia vera 365 Polygenic inheritance 45 Polymorphic VT 121 Polymyositis 595 Poor prognostic factors 376, 547, 593 indicators 327, 335 Portal hypertension 321 Index 835 Position sense 505 Positive phenomena 502 Positron emission tomography 792 Posterior spinal artery syndrome 570 Posterolateral sclerosis of spinal cord 586 Postinfectious GN 408 Postnecrotic cirrhosis 319 Postprimary pulmonary tuberculosis 242 Postulated mechanisms for ageing 762 Potassium 67, 421 Practical classification of anaemia 347 Precautions after seizure attack 515 Precipitating factors for epilepsy 511 Precocious puberty in females 643 males 644 Predisposing conditions 365 factors 247, 249, 254, 258, 561, 574, 665 Predominant LMN involvement 547 UMN involvement 548 Pregestation diabetes mellitus 677 Pregnancy 381 Pregnancy and alcohol 773 diabetes 675 SLE 710 Preleukaemic syndromes 378 Premature sexual developmental disorders 643 Preparation of patient 392 Preproliferative retinopathy 667 Prevention of caries 69 hepatitis 314 Primary cardiomyopathies 192 hyperlipoproteinaemias resulting 684 hyperparathyroidism 629 immunodeficiency disorders 49 lateral sclerosis 548 lymphoid organs 46 myelosclerosis 367 skin lesions 23 thrombocytosis 366 tuberculosis 240 Primitive reflexes 498 Principles of cancer therapy 745 chemotherapy 746 management of geriatric problems 767 treatment of UTI 403 Progressive bulbar palsy 547 medullo-spinal compressions 588 muscular atrophy 547 systemic sclerosis 712 Proliferative retinopathy 668 Prolonged QTC interval 114 Prophylaxis for UTI 404 Proprioceptive sensations 505 Prostate cancer 731, 732, 754 Prosthetic sounds 101 Proteins 55 Proteinuria 398 Pruritus 729, 756 Pseudo coma 429 Pseudobulbar palsy 548 Pseudohypertension 89 Pseudohypoparathyroidism 633 Pseudopseudohypoparathyroidism 633 Pseudoseizures 517 Pseudo-von Grafe’s sign 456 Psoriatic arthritis 708 Pulmonary angiography 226 artery 146 hypertension 264 regurgitation 160 stenosis 135, 137, 160 thromboembolism 266 Pulsatile liver 283 Pulse character 83 rate 82 volume 83 Pupillary reflexes 458 Pure vitamin E deficiency 552 Pyrexia of unknown origin 30 Pyridoxine 64 excess 64 Q Qualitative platelet disorders 386 Quantitative platelet disorders 386 Queckenstedt’s test 808 Quinidine effect 114 R Radiation therapy 745, 759 Radio-femoral delay 87 Radiofrequency ablation 118 Radioimmunotherapy 746 Radioisotope scanning 791 Radionuclide therapy 746 Ramsay Hunt syndrome 557 Rapidly progressive GN 409 Rectal cancer 748 Recurrent pneumoniae 248 transitory attacks 588 Red nail 26 Reducing substances in urine 401 Reflexes 490 Refsum’s disease 595 Regions of abdomen 273 Reid index 235 Reiter’s disease 707 Released reflexes 498 Renal and ureteral infections 735 Renal cell carcinoma 727, 730, 732, 754 failure 682 pain 36 system 697 transplantation 418 Respiration 432 Respiratory causes 33 diseases 227 system 199, 697, 774 Response to treatment 747 Restrictive cardiomyopathy 191 diseases 227 Reticulocyte index 345 Retinol 59 Rheumatic fever 146 Rheumatoid arthritis 696 Riboflavin 63 Rickets 60 Riedel’s struma 627 thyroiditis 627 Right and left sided heart failure 164 Right atrial enlargement 107 bundle branch block 108 sided effusions 255 ventricular hypertrophy 108 infarction 187 Risk factors for alcoholic liver disease 770 deep vein thrombosis 266 diabetic retinopathy 668 stroke 519 type diabetes mellitus 646 Romberg’s test for position sense 506 Rotor syndrome 308 Rubeosis iridis 668 Rule of 504 hundreds for tachycardias 115 836 Manual of Practical Medicine S Sarcomas 755 Saturday night palsy 773 Scale for grading pain 755 Schober test 706 Scurvy 65 Second cranial nerve 447 heart sound 98 malignancy 758 wind angina 80 Secondary adrenal insufficiency 638 cardiomyopathies 192 hyperaldosteronism 634 hyperlipoproteinaemias 686 hyperparathyroidism 632 immunodeficiencies 50 lymphoid organs 46 Secretory diarrhoea 293 tumours 611 Seizures 741 Selection of donor 392 Selenium 70 Semiconsciousness 428 Sensory dermatomes 504 dissociation 508 pathways 502 system 502 Sepsis 682 Seronegative arthritis 705 Serum biochemistry 823 enzymes 304, 823 Setting up drip 813 Seventh cranial nerve 465 Severity of haemoptysis 202 Sexual disorders 643 Shift-work sleep disorders 441 Shock 39, 95 Shortened QTC interval 114 Sick sinus syndrome 122 Sickle cell disease 357 Sideropenic anaemia 354 Signs and symptoms of hypoglycaemia 680 Signs of liver cell failure 272 pyramidal tract lesion 476 wide pulse pressure 156 Silent thyroiditis 626 Simple anaemia 354 Single gene disorders 43, 127 mutations 684 Site of lesion 741 Skeletal defects 15 Skin 699, 774 cancer 728 in clinical medicine 22 Sleep 437 apnoea syndromes 440 bruxism 441 centre 438 disorders associated with medical or psychiatric disorders 439 with neurologic disorders 441 enuresis 441 terrors 440 Slow virus disease 562 Small bowel 773 cancer 727, 729, 731 Small muscle wasting of hand 479 Smoking 775 Smoking and body weight 777 cardiovascular disease 776 depression 777 drugs 777 gastrointestinal disorders 777 pregnancy 777 respiratory disease 777 Smoking index 777 Sodium 66, 419 Somnambulism 440 Speech areas 442 Spinal cord 568 compression 741 disorders 570 enlargements 568 tumours 541 muscular atrophy 550 syphilis 572 Spine 567 Spinomotor system 475 Spirometry 221 Spleen 276 Splenomegaly 283 Spontaneous bacterial peritonitis 324 pneumothorax 255 Spontaneously resolving hyperthyroidism 626 Sputum 201 examination 220 Squint 459 S-T segment depression 110 elevation 110 Stages in diabetic nephropathy 675 Stages of care in diabetic pregnancy before conception 677 hair follicle growth State of nutrition 17 Statistical risk disease 646 Status epilepticus 515 Steatosis 316 Stem cell diseases 342 Stereognosis 508 Stomach 773 Stool 824 Storage disorders 283, 284 Strabismus 459 Stress ulcer 288 Stroke 518 Structural aberration of chromosome 43 Stupor 428 Sturge-Weber syndrome 518 Subacute combined degeneration 586 sclerosing pan encephalitis 562 thyroiditis 625 Subarachnoid haemorrhage 534 Sub-clavian Steal syndrome 530 Sub-clinical hypothyroidism 624 Substance abuse 769 Success rate 339 Superior vena caval obstruction 738 Suppurative thyroiditis 625 Surface marking of organs 275 Surface of abdomen 274 Surgery 745 Sustained monomorphic VT 121 Sweat 824 Swinging light test 451 Symptom control in severe cancer 755 Symptoms of UTI 402 Syncope 80 Syndrome of inappropriate antidiuretic hormone secretion 615 Syndromes associated with phaeochromocytoma 641 Syndromes with ASD 128 PDA 131 VSD 130 Syphilis 572 Syringobulbia 585 Syringomyelia 583 Index 837 Systemic hypertension 171 lupus erythematosus 708 Systolic murmurs 101 Systolico-diastolic murmur 105 T Tabes dorsalis 572 Tachyarrhythmias 115 Takayasu’s arteritis 719 Target organ resistance 633 TB meningitis 242 Technique of auscultation 215 Teletherapy 746 Temporal arteritis 719 Tenderness over chest wall 212 Terminology of skin lesions 23 Terry nail 26 Tertiary hyperparathyroidism 632 Test of vestibular function 471 Testicular cancer 728, 731, 732, 754 Testing of sternocleidomastoid muscle 474 trapezius muscle 474 visual acuity 448 fields 448 Testing sense of smell 446 Tests for nerve root compression 576 Tests of biosynthetic function 304 cholestasis 305 Tetralogy of Fallot 133, 137 Thalassaemia 358 Theories of clubbing 205 Therapeutic application of stem cells 342 oesophagogastro-duodenoscopy 291 Therapy of selected cancers 748 Thiamine 63 Thick-walled cavity 220 Thin-walled cavity 220 Third heart sound 99 Thomson’s disease 600 Thrills 95 Thrombocytopenia 388 Thrombocytosis 366 Thrombotic thrombocytopenic purpura 388 Thunderclap headache 535 Thymoma 601 Thyroid disorders 616 gland 616 scan 794 storm 620 Thyroiditis 625 Thyrotoxic crisis 620 Timed vibration sense 507 T-lymphocytes 47 TNM classification 732 To-and-fro murmurs 104 Tobacco alcohol amblyopia 773 Tongue 10 Tongue in neurology 12 Toxicity of radiation therapy 746 Toxins 283 Tracheal tug-Olliver’s sign 210 Tracheostomy 819 tubes 820 Transient hypertension 89 Transport phase 295 Traumatic lesions of spinal cord 571 pneumothorax 256 Treatable cerebellar lesions 501 Treatment for diabetic erectile dysfunction 673 Treatment of acute heart failure 165 GBS 593 reactive hypoglycemia 683 SAH 536 Treatment regimens in special situations 244 Trephine biopsy 811 Trepopnoea 79 Tricuspid atresia 143 regurgitation 159 stenosis 158 Tri-fascicular block 110 Trigeminal nerve 463 Triggering factors 696 Trinucleotide repeat 45 Tropical pancreatitis 337 Truncus arteriosus 143 Tuberculosis 240, 247, 572 Tuberculosis of abdomen 295 Tuberous sclerosis 517 Tubulointerstitial disease 410 of kidney 410 Tumour antigens 52 lysis syndrome 757 suppressor genes and familial cancers 724 Twelfth cranial nerve 475 Two-point discrimination 507 Type I hypersensitivity 50 II hypersensitivity 50 III hypersensitivity 50 IV hypersensitivity 51 Types of alopecia AVM 536 bone marrow transplantation 392 bronchial breathing 216 endotracheal tubes 820 fibrosis 220 haemoptysis 202 muscle wasting 478 obesity 72 smoking 778 tracheostomy 819 wheeze 217 U Ultrasound 792 scan 225 UMN fibres corticobulbar tracts 548 Unresolved pneumoniae 248 Unusual features in GBS 593 Upper gastrointestinal endoscopy 290 motor neuron lesions 460 retrosternal pain 204 Uraemia 113 Urethral catheterisation 818 Urinary obstruction 743 tract infection 401 tract infection 402 Urine 824 analysis 396 V Vaccination of cancer patients 735 Vagus nerves 473 Valve replacement 151 Valvular clicks 100 heart disease 147 Variant forms of myeloma 382 Variants of motor neuron disease 548 rheumatoid arthritis 699 Variceal bleeding 322 Various sensory lesions 508 838 Manual of Practical Medicine Vascular clicks 100 syndromes of spinal cord 569 Vasculitis syndromes 715 Ventilation-perfusion imaging 225 Ventricular level shunt 124 septal defect 129 Vertigo 471 Very low density lipoprotein 684 Vestibular neuronitis 473 Vestibulocochlear nerve 469 Vibration sense 506 Viral hepatitis 308 Virilism 644 Viruses causing malignancy 726 Visuospatial functions 436 Vitamin 59 A 59 B1 63 B12 65 B2 63 B6 64 C 65 D 60 deficiency 60 E 62 K 62 Voice sounds 218 von Hippel Lindau syndrome 518 W Wasted leg syndrome 549 Watershed areas of spinal cord 570 Water-soluble vitamins 63 WBC count 347 Wegener’s granulomatosis 718 Whiplash or flexion extension injury 572 White clot syndrome 388 hypertension 89 White nail 26 Wilson’s disease 330 Withdrawal syndrome 772 World Health Organisation classification 369 X Xeroderma pigmentosum 553 X-linked ataxia 553 dominant inheritance 44 recessive inheritance 44 X-ray hands 788 Y Yellow nail syndrome 26 Young stroke 527 Z Zinc 69, 634 deficiency 634 Zollinger-Ellison syndrome 289 ... usually of unpleasant nature and characteristic of epilepsy arising in the uncinate gyrus of temporal lobe They may also occur in psychosis 448 Manual of Practical Medicine Some Common Features of. .. oedema of the optic disc > dioptres (Fig 8.14) 4 52 Manual of Practical Medicine Fig 8.14: Papilloedema There are stages of papilloedema Early Papilloedema a Earliest change is blurring of superior... Functional areas of cerebral cortex non-fluent speech, with reduced number of words, with errors of grammar and syntax Wernicke’s area (sensory speech area/posterior part of area 22 and parietotemporal